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Contents
Executive summary
Assessment and recommendations
Chapter 1. Mental health and work challenges in Norway Chapter 2. Reconsidering Norwegian sickness absence policies
Chapter 3. Revising disability benefit assessment procedures and eligibility criteria in Norway
Chapter 4. Enhancing the effectiveness of Norway’s vocational rehabilitation system Chapter 5. Involving mental health care in Norway in employment issues
Chapter 6. Following up in the school-to-work transition in Norway
Further reading
Sick on the Job? Myths and Realities about Mental Health and Work (2012) Mental Health and Work: Belgium (2013)
Mental Health and Work: Denmark (2013) Mental Health and Work: Sweden (2013)
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http://dx.doi.org/10.1787/9789264178984-en
Foreword
Tackling mental ill-health of the working-age population is becoming a key issue for labour market and social policies in many OECD countries. It is an issue that has been neglected for too long despite creating very high and increasing costs to people and society at large. OECD governments increasingly recognise that policy has a major role to play in improving the employment opportunities for people with mental ill-health, including very young people; helping those employed but struggling in their jobs; avoiding long-term sickness and disability caused by a mental disorder; and involving treating physicians more in job retention and rehabilitation.
A first OECD report on this subject, Sick on the Job? Myths and Realities about Mental Health and Work, published in January 2012, identified the main underlying policy challenges facing OECD countries by broadening the evidence base and questioning some myths around the links between mental ill-health and work. This report on Norway is one in a series of reports looking at how these policy challenges are being tackled in selected OECD countries, covering issues such as the effectiveness of sickness and disability benefits and vocational rehabilitation, the capacity of the health care system, and the transition from school to work. The other reports look at the situation in Australia, Austria, Belgium, Denmark, the Netherlands, Sweden, Switzerland and the United Kingdom. Together, these nine reports aim to deepen the evidence on good mental health and work policy. Each report also contains a series of detailed country-specific policy recommendations.
Work on this review of Norway was a collaborative effort carried out jointly by the Employment Analysis and Policy Division and the Social Policy Division of the OECD Directorate for Employment, Labour and Social Affairs. The country mission was undertaken by Shruti Singh from the OECD and Niklas Baer from the Psychiatric Services of Baselland (Switzerland). The report was prepared by Niklas Baer under the supervision of Christopher Prinz. Statistical work was provided by Dana Blumin. Valuable comments were provided by John Martin and Mark Keese. The report also includes comments received from various Norwegian ministries and authorities.
Special thanks go to Arne Kolstad and Bjørn Halvorsen from the Ministry of Labour who accompanied the OECD team during the country mission and supported the development of the report.
Table of contents
Acronyms and abbreviations ... 9
Executive summary ... 11
Assessment and recommendations ... 13
Chapter 1. Mental health and work challenges in Norway ... 19
Introduction: definitions and objectives ... 20
High mental health-related social inequalities in Norway ... 22
Organisational characteristics of the systems involved ... 29
References ... 34
Chapter 2. Reconsidering Norwegian sickness absence policies ... 35
The trap of high and prolonged sickness absence... 36
A new responsibility and funding architecture for sick leave... 42
New criteria for sickness benefit eligibility and non-eligibility ... 46
Summary and conclusions ... 52
References ... 54
Chapter 3. Revising disability benefit assessment procedures and eligibility criteria in Norway ... 57
Disability benefit as a frequent one-way road ... 58
Applying existing disability benefit regulations as intended ... 64
Revising the disability assessment process ... 68
Changing the character of disability benefits ... 71
Matching responsibility and funding structures for disability benefit ... 75
Introducing reassessments of disability beneficiaries ... 76
Summary and conclusions ... 78
References ... 79
Chapter 4. Enhancing the effectiveness of Norway’s vocational rehabilitation
system ... 81
The current focus of vocational rehabilitation ... 82
Reconsidering the direction of vocational rehabilitation ... 83
Making the most of a strong rehabilitation structure ... 88
Summary and conclusions ... 92
References ... 93
Chapter 5. Involving mental health care in Norway in employment issues ... 95
Shortcomings of the mental health care system... 96
Integrating mental health and employment services ... 100
Summary and conclusions ... 107
References ... 109
Chapter 6. Following up in the school-to-work transition in Norway ... 111
Discontinued education multiplies the problems ... 112
Better school-to-work transition for youth with mental ill-health ... 115
Summary and conclusions ... 120
References ... 122
Figures Figure 1.1. Norway has the highest mental health-related unemployment gap ... 23
Figure 1.2. In Norway, employment rates of people with a mental disorder declined during the period of strong growth up to the recent crisis ... 25
Figure 1.3. Mental disorders are particularly frequent among the unemployed ... 26
Figure 1.4. The risk of poor mental health varies by education ... 27
Figure 1.5. Norway ranks first in several key policy parameters ... 28
Figure 2.1. Norway has the highest sickness absence rate by far ... 36
Figure 2.2. An increasing share of sick leave is caused by mental illness ... 38
Figure 2.3. Mental conditions are frequent among long-term absences and their share is increasing ... 39
Figure 2.4. Long-term absences have increased in common mental disorders ... 40
Figure 2.5. Sickness leaves with a mental disorder are often partial leaves ... 48
Figure 2.6. GPs perceive sickness certification as quite problematic ... 50
Figure 3.1. High and increasing disability beneficiary rates in Norway ... 60
Figure 3.2. New disability benefit claims with a mental condition have increased in all age groups ... 61
Figure 3.3. Norway has very low disability benefit claim rejection rates ... 63
Figure 3.4. Outflow from disability benefits into employment is close to zero ... 64
Figure 3.5. Temporary benefits are rare for older people with mental disorders .... 66
Figure 3.6. Moderate mental disorders are prevalent in older disability
beneficiaries ... 67
Figure 3.7. Strong increase in the past two decades in disability benefits due to a mental disorder for young adults ... 74
Figure 3.8. Symptoms typically improve after disability benefit award ... 76
Figure 4.1. Training is the predominant vocational measure used in Norway ... 82
Figure 4.2. The use of workplace-based interventions has increased ... 83
Figure 4.3. Response by SMEs to alternative measures to boost the hiring of people with a disability ... 84
Figure 5.1. Hospitalisations are becoming shorter, but readmissions remain frequent ... 98
Figure 5.2. More GPs and psychiatrists in Norway than in most other countries .. 99
Figure 6.1. Around one in four young people have a mental disorder ... 112
Figure 6.2. Early school-leaving is frequent in Norway partly because of a high drop-out rate from vocational education ... 113
Figure 6.3. The composition of mental disorders leading to a disability benefit claim among young people is changing ... 114
Acronyms and abbreviations
ADHD Attention-Deficit and Hyperactivity Disorder
GP General Practitioners
HIS Health Interview Survey
IAPT Improving Access to Psychological Therapies (IAPT) ICD International Classification of Diseases
IWA Inclusive Workplace Agreement
NAV Norwegian Labour and Welfare Administration NEET Neither Employed nor in Education
NHS National Health Survey
NIS Norwegian Social Insurance Scheme
NOK Norwegian Krone
PPS Educational and Psychological Counselling Services
WAA Work Assessment Allowance
Executive summary
Throughout the OECD, mental ill-health is increasingly recognised as a problem for social and labour market policy; a problem that is creating significant costs for people, employers and the economy at large by lowering employment, raising unemployment and generating productivity losses. This also applies in Norway which has the highest sickness absence incidence and disability benefit caseload in the OECD despite a traditionally strong work-first approach. In view of Norway’s economic performance as well as the high level of spending on health care and education, mental health-related inequalities seem very high. Norwegian policy makers recognise the need for action to prevent people from dropping out of the labour market with a mental illness and help those with a mental disorder in finding jobs. Accordingly, Norway has established a broad range of policies and reforms to tackle the exclusion of people with mental ill-health. These include a national strategy on work and mental health, developed jointly by the Ministry of Health and the Ministry of Labour; and the integration of the public employment service, the social insurance and parts of the municipal social assistance into a Labour and Welfare Administration (NAV), thus offering a strong structure for early intervention and co-ordinated support.
Despite sound policies and support services, however, fundamental change is needed in order to improve the situation for the people concerned.
Change will need to include the recognition that the perspective of an easy access to sickness absence and permanent disability benefit play to the characteristics of most people with mental health problems, namely fears and avoidant behaviour. Further changes should include improving the cooperation between mental health care and NAV services; supporting employers at an early stage of a mental health-related workplace problem;
and tackling the high rate of dropout from upper secondary education due to mental health problems.
The OECD recommends to Norway to:
x Take action to avoid sickness absence of workers with mental health problems as much as possible and instead solve the problems at the workplace.
x Expand the Employment Support Centres of NAV to fill the wide gap between general prevention and rehabilitation by introducing and expanding early intervention measures.
x Stop the fragmentation of services in mental health care and rehabilitation and the disconnection between treating physicians and NAV by developing integrated support models.
x Minimise school dropout and improve the transition to employment by defining clear responsibilities for on-going individual follow-up for students at risk.
Assessment and recommendations
Norway combines a unique mix of a favourable economic and labour force situation and very high investments in education and health with a pervasive exclusion of people with health problems from the labour market.
While the Norwegian system has generated a high and stable employment rate over the last decades, one-fifth of the population receives income supports due to health problems, and spending on disability and sickness benefits amounts to around 5% of GDP, by far the highest level in the OECD. The causes for this combination cannot be found either in a lack of vocational rehabilitation policies or a lack of elaborated support structures;
both are well developed. Rather, the reasons lie in a political reluctance to revise a very generous social protection system; to implement effectively far-reaching changes introduced in the past decade; and to enforce new obligations rigorously.
Blocking the exclusion perspective
For many people with a mental disorder, the welfare-driven strategy has the contrary effect of exclusion and inequality: people with a severe mental disorder have a nine-fold unemployment rate compared with the national average and, more generally, Norwegians with a mental disorder did not benefit from the favourable labour market situation in the period leading up to the recent crisis, as reflected in falling employment and rising unemployment rates for this group. Relatively easy access to long-term or permanent work incapacity benefits not only plays to some typical characteristics of mental illness like, for instance, fear avoidance, withdrawal and passivity, but also isolates people with mental disorders from the world of work.
To improve labour market access and job retention of people with a mental disorder, perspectives should be changed. Employees with a mental health problem are more frequently taking long-term sick leave compared with people with a physical health problem, and their sickness rates have steadily increased, despite an elaborate system of sickness absence monitoring. Similarly, the drop-out rate of clients with a mental disorder
from vocational rehabilitation programmes is high despite a strong work- first approach and a broad range of supports over several years. Finally, disability benefit claims are seldom rejected and, once awarded, rarely reassessed, although beneficiaries with a more moderate mental disorder typically have a fluctuating work capacity. To improve the effectiveness of existing measures, the perspective of long-term sick leave and permanent disability benefit should in many cases be blocked from the beginning.
Matching responsibilities and funding structures
Responsibility for sickness and disability benefits is very unequally distributed, with the bulk of the costs covered by social insurance.
Employers have a key role in preventing sick leave and supporting the return-to-work process, but are financially involved in short-term absences only, reducing their efforts to avoid harmful long-term sick leave.
Employees also face limited incentives to avoid sickness absence, receiving compensation equal to 100% of their previous wage for up to one year.
Co-workers represented by their unions, and the physicians’ certification behaviour also influence workplace dynamics and return-to-work, but unions and doctors do not bear any of the financial costs of their decisions.
Finally, the municipalities – responsible for health, education and rehabilitation services – have much impact on the rates of exclusion, but are not involved in health-related work incapacity funding either. Although it is difficult to quantify the responsibility of each actor, new ways of co-financing should be discussed to improve their commitment to labour market inclusion of people with mental ill-health.
Reconsidering sickness absence policies
Norway has, by far, the highest rate of sickness absence in the OECD.
Despite a recent focus on partial sickness leave, full-time sick leave is still the rule. General practitioners (GPs) are responsible for sickness certification, but they find it difficult to assess the duration, degree and future development of functional capacity. Sickness absence regulations are quite elaborate but there is no early identification of sick leaves due to mental illness. Medical and vocational professionals come in too late in the process, if at all, and the elaboration of a return-to-work plan is left to the employer and the employee.
Managers and human resource professionals are not trained sufficiently to identify and intervene in mental health problems. The strong focus of existing services such as occupational health services or the labour inspection authority on sickness prevention and health promotion, results in a lack of targeted early intervention and support to employers.
Revising disability assessment procedures and eligibility criteria The eligibility criteria for a disability benefit are strict in Norway requiring a permanent loss of work capacity and excluding social problems or milder mental disorders. Nevertheless, common mental disorders like mood and neurotic disorders are the main reason for a disability benefit in people with mental health problems, especially in older age. The strict eligibility rules do not always seem to be followed. Moreover, around one- third of the new beneficiaries have never sought treatment for their mental health problem. The possibility to receive a disability benefit after several years of vocational rehabilitation undermines the seriousness of the integration efforts. Another potential problem lies in the disability assessment process itself, which is influenced significantly by the claimants;
often takes place without the involvement of a mental health specialist; and lacks a focus on periodic reassessment.
Improving the outcomes of vocational rehabilitation
The many different vocational rehabilitation services in Norway support an increasing number of clients. However, education and training are still the most frequently used measures despite a modest effectiveness, and they are used mostly as re-education measures for persons with higher education rather than to up-skill people with low education. Conversely, wage subsidies to employers, which are rather effective, are hardly used. Finally, the large group of people at risk of dropping out of the labour market but still at work is not reached by vocational rehabilitation. The existing employer support centres could offer a basis for support to employees struggling in work provided these centres would be expanded; turned into multidisciplinary services; and given responsibility for individual follow-up.
Strengthening health care integration
The disintegration of mental health care and employment services, as well as the fragmentation within the mental health system itself with municipal primary care and regional specialist care, is a main barrier for labour market inclusion. The pioneering Norwegian strategy for work and mental health has tried to build a bridge between the Labour and Welfare Administration (NAV) and the health care sector. In order to yield sustainable improvements, however, structural measures are needed. For instance, the few insurance physicians in the NAV offices are not allowed to see the claimants; when in treatment, the significance of the patient’s employment situation is undervalued; and many people on sick leave have an undetected mental disorder indicating a need for improved co-operation between general and specialist care. A more integrated approach is also hindered by a lack of inter-sectoral routine data. Finally, while people with a
severe mental disorder and more generally all those who can afford private psychotherapy seem to have good access to mental health services, the majority of people with moderate disorders and working problems have long waiting times for psychiatric treatment.
Due to the early onset of most psychiatric disorders and the importance of a good education for future performance in the labour market, mental health problems in pupils should be tackled in concerted action. This would be important because non-completion of upper secondary education is common in Norway, especially in apprenticeships. There are a number of obstacles: pedagogical and psychological services are not obliged to co- operate with health services; general health services often do not refer young patients to specialists; and teachers do not receive enough support. In case of inward-oriented mental disorders not associated with difficult behaviours or emotions, the chance to get specialist treatment is low. Finally, there are no services and no integrated concepts to systematically secure a successful and sustainable transition to work.
Summary of the main OECD recommendations for Norway Key policy challenges Policy recommendations
1. There is a lack of incentives to avoid sick leave or to support early return-to-work
x Increase the duration of the sickness payment obligation for employers, or introduce co- financing for the entire sick-leave period.
x Reduce the replacement rate in case of sickness absence from 100% to around 80%.
x Discuss a co-financing of health-related work incapacity costs by unions and municipalities.
2. Employers are not equipped to deal with mental health problems in the workplace
x Develop criteria for rapid intervention by NAV and the treating physician in case of mental health-related work problems or sick leave.
x Expand resources and responsibilities of the Employer Support Centres to secure earlier intervention, support for employers and follow- up of employees in need of help.
x Develop integrated processes for employers, NAV professionals and physicians to co- operate in case of employees' non-compliance.
3. GPs feel uncertain in assessing sickness absence duration and work capacity
x Assure as little and short sick leave as possible for common mental disorders.
x Train physicians in dealing with workplace problems of patients, and strengthen sanctions for systematically non-compliant physicians.
x Base long-term sickness certifications on an interdisciplinary assessment which involves a specialist and a NAV professional.
4. Strict disability benefit eligibility is not applied in practice
x Expand explicit social and medical exclusion criteria for a disability benefit.
x Request an adequate specialist treatment before awarding a disability benefit on the grounds of a mental disorder.
x Strengthen the requirements on compliance with rehabilitative measures and apply them rigorously in practice.
x Base disability benefit awards on an interdisciplinary assessment rather than merely the existing medical record.
5. There is no outflow from disability benefits into employment
x Introduce periodic reassessments of disability benefit entitlements.
x Provide better incentives for municipalities and enterprises to offer jobs for disability beneficiaries and provide long-term follow-up to employers and beneficiaries.
Summary of the main OECD recommendations for Norway (cont.) Key policy challenges Policy recommendations
6. Vocational rehabilitation measures are not as effective as possible
x Provide more workplace-oriented job retention services targeting employers and employees.
x Decrease the share of education and training measures for people with mental disorders in favour of the provision of wage subsidies.
x Provide education measures above all to people with low education (up-skilling).
x Define rehabilitative programme packages for relevant target groups.
7. Mental health care and employment support are not integrated
x Develop collaboration between NAV, local GPs and District Psychiatric Centres.
x Install NAV professionals in the District Psychiatric Centres.
x Partly integrate GPs into the NAV offices.
8. The mental health sector has no systematic focus on employment
x Establish work-related issues as a core competence in the District Psychiatric Centres.
x Implement employment as a main outcome in mental health care and develop work-related health care quality indicators.
x Develop an employment and workplace-related mental health training curriculum for GPs.
x Develop a screening tool for doctors to detect mental health problems in general practice.
9. High rates of school dropout and increasing disability benefit rates among young adults
x Increase the resources of school-based health services and ensure an integrated approach with the Pedagogical and Psychological Services.
x Establish a close contact between vocational education, NAV professionals and municipal health services.
x Expand the Qualification Programme explicitly to youth with mental health problems and secure identification and treatment.
Chapter 1
Mental health and work challenges in Norway
This chapter refers to the key findings of the recently published OECD report Sick on the Job? and summarises the characteristics of people with mental health problems which contribute to the special challenges in job retention and labour market re-integration for this group. The high mental health-related employment inequalities in Norway are discussed and compared with those in other countries. The chapter also provides a description of some organisational characteristics of the systems involved.
Introduction: definitions and objectives
The OECD report Sick on the Job? Myths and Realities about Mental and Work concluded that a three-fold shift in policy is required to respond effectively to the challenges of ensuring greater labour market inclusion of people with mental illness (OECD, 2012). More attention needs to be given to i) mild and moderate mental disorders as opposed to severe disorders;
ii)disorders concerning the employed and unemployed; iii) early intervention instead of rehabilitation of people with mental disorders ; and iv) systematically integrating health care with support systems in education and social insurance.
Understanding the characteristics of mental ill-health is critical for devising the right policies. The key attributes of a mental disorder are above all an early age at onset. The median age of onset of mental disorders is around 14 years. This implies i) most people struggling at work have been vulnerable long before they get contacted by support systems; ii) many of the later beneficiaries already had problems at school and during the transition to the labour market; and iii) many of them have not had a stable work biography. The early onset hits children and adolescents in the middle of the development of their personality often resulting in “difficult” and uncertain personalities.
Further key attributes of mental disorders are its severity; its persistence and chronicity; a high rate of recurrence; and a frequent co-existence with physical or other mental illnesses. The more severe, persistent and co-morbid the illness, the greater is the degree of disability associated with the mental disorder and the potential impact on the person’s work capacity.
However, contrary to physical problems milder and even sub-clinical forms of mental health conditions can be disabling if they persist over a longer period. The diagnosis also matters, e.g. schizophrenia and personality disorders have a relatively bad employment prognosis. At the same time, mental illness of any type can be severe and persistent. The majority of mental disorders fall in the category mild or moderate, often including affective and neurotic disorders. The symptoms of these disorders are mostly well treatable, but there remain two barriers, which are not solved so far: i) professional treatment can remedy the symptoms of the illness, but it cannot “cure” a vulnerable personality; and ii)often treatment is not sought, or treatment is not effective with respect to work outcomes.
One important general challenge for policymakers is the very high rate of non-awareness, non-disclosure and non-identification of mental disorders – which is directly linked with the stigma attached to mental illness. The early onset, its potential consequences for failures in education and work, and its impact on the early building of an often uncertain
personality, combined with the fears and prejudices of the environment, reduce the chances of disclosure and treatment seeking – which would be the usual behaviour in people with physical problems.
The OECD report Sick on the Job? Myths and Realities about Mental and Work identified two main directions for reform. First, more emphasis needs to be given to (early) identifying of problems and needs; and intervening at key stages of the lifecycle, including during the transition from school to work, at the workplace, and when people are about to lose their job or to move into the benefit system. Secondly, a coherent approach across government services needs to be taken which integrates health, employment and, where necessary, other social services.
Mental disorder in this report is defined as mental illness reaching the clinical threshold of a diagnosis according to psychiatric classification systems such as the International Classification of Disease (ICD-10) which is in use since the mid-1990s (ICD-11 is currently in preparation). Based on this definition, at any moment some 20% of the working-age population in the average OECD country is suffering from a mental disorder, with lifetime prevalence reaching 40-50% (Box 1.1).
The purpose of this report is to examine how policies and institutions in Norway are addressing the challenge of ensuring that mental ill-health does not mean exclusion from employment and that work itself contributes to better mental health. A number of specific issues are addressed. How are the critical institutions and stakeholders – schools, employers, employment services and psychiatric services – organised and resourced to identify people with a mental disorder? What is done and how quickly when a problem has been identified, and what is done more generally without stigmatising those in need? How are the different actors in Norway co-operating and how are different services integrated to ensure people get the right services quickly to access the labour market, remain in their job or return to employment?
The structure of the report is as follows. This first chapter sets the scene by looking at key social and labour market outcomes for people with a mental disorder, in Norway compared with other countries, and describing the organisational characteristics of the main systems catering for people with mental illness. This is followed by chapters which look consecutively at the policy challenges Norway is facing in a number of key areas: the sickness benefit scheme; the disability benefit scheme; the vocational rehabilitation scheme; the mental health system; and the education system.
Each chapter concludes with specific policy recommendations.
Box 1.1. The measurement of mental disorders
Administrative clinical data and data on disability benefit recipients generally include a classification code on the diagnosis of a patient or benefit recipient, based on ICD-10, and hence the existence of a mental disorder can be identified. This is also the case in Norway.
However, administrative data do not include detailed information on an individual’s social and economic status and they cover only a fraction of all people with a mental disorder.
On the contrary, survey data can provide a rich source of information on socio-economic variables, but in most cases only include subjective information on the mental health status of the surveyed population. Nevertheless, the existence of a mental disorder can be measured in such surveys through a mental health instrument, which consists of a set of questions on aspects such as irritability, nervousness, sleeplessness, hopelessness, happiness, worthlessness, and the like, with higher values indicating poorer mental health. For the purposes of the OECD review on Mental Health and Work, drawing on consistent findings from epidemiological research across OECD countries, the 20% of the population with the highest values according to the instrument used in each country’s survey is classified as having a mental disorder in a clinical sense, with those 5% with the highest value categorised as “severe” and the remaining 15% as “mild and moderate” or “common” mental disorder.
This methodology allows comparisons across different mental health instruments used in different surveys and countries. See www.oecd.org/els/disability and OECD (2012a) for a more detailed description and justification of this approach and its possible implications.
Importantly the aim here is to measure and compare the social and labour market outcomes of people with a mental disorder, not the prevalence of mental disorders as such.
For this report, data from the Norwegian Level of Living and Health Survey for 1998 and 2008 are used to estimate labour market outcomes of the target population. The mental disorder variable in this survey is based on the HSCL-25 Hopkins Symptom Checklist, a validated self- rating scale with 25 questions on the presence and intensity of anxiety and depression symptoms over the previous week.
High mental health-related social inequalities in Norway
Norway has a high overall standard of living and generous benefits for disadvantaged people, but also a relatively equal distribution of opportunities in the population as regards income, housing and access to services. Numerous regulations and measures have been created to guarantee equal rights and possibilities for vulnerable groups. In view of this, resulting inequalities depending on mental health status are rather large.
Mental health-related employment differences are large
Although Norway has very high rates of employment for people without a mental disorder (around 85%), the employment rate for people with a severe mental disorder, at 55%, is lower than in comparable or neighbouring countries such as Switzerland (65%) and Denmark (60%). Many people with mental health problems cannot participate in the healthy Norwegian labour market. The participation gap between healthy individuals and people with mental health problems is even larger in terms of unemployment (Figure 1.1).
Figure 1.1. Norway has the highest mental health-related unemployment gap Unemployment rates by mental-health status (percentages; left axis) and relative unemployment ratios
(people with mental disorders over those without such a disorder; right axis) in the late 2000s
Source: OECD calculations based on national health surveys (NHS) or interview (HIS) surveys.
Australia: NHS 2007/08; Austria: HIS 2006/07; Belgium: HIS 2008; Denmark: NHIS 2005;
Netherlands: POLS Health Survey 2007/09; Norway: Level of Living and Health Survey 2008;
Sweden: Survey on Living Conditions 2009/10; Switzerland: Health Survey 2007; United Kingdom:
Adult Psychiatric Morbidity Survey 2007; United States: NHIS 2008.
Panel B. Moderate mental disorders Panel A. Severe mental disorders
0.0 1.5 3.0 4.5 6.0 7.5 9.0
0 5 10 15 20 25 30
Austria Sweden Belgium United Kingdom
United States
Norway Australia Netherlands Denmark Switzerland Moderate No disorder Relative: moderate/no disorder (right axis)
0.0 1.5 3.0 4.5 6.0 7.5 9.0
0 5 10 15 20 25 30
Austria Sweden Belgium United Kingdom
United States
Norway Australia Netherlands Denmark Switzerland Severe No disorder Relative: severe/no disorder (right axis)
People with a severe mental disorder have a nine-fold unemployment rate (Figure 1.1, Panel A), and those with a moderate mental disorder a three-fold rate (Panel B), compared with people without a mental health problem. It is not the level of unemployment (15% for severe and 5% for moderate mental disorders) which is striking but the strong unemployment gap with healthy people. Selection effects alone cannot explain this difference, as the much lower gap in Switzerland – which has a comparably low level of unemployment – shows.
Substantial and increasing mental health-related income gaps
The employment disadvantages for individuals with mental health problems also result in relatively low income levels (OECD, 2012). At below 80% of the average income, the income gap with respect to the incomes of healthy people is larger than in other countries such as Austria, Belgium, Denmark, Sweden and Switzerland. This suggests that people with a mental disorder who are employed stay on a relatively low income level.
Moreover, people with severe mental disorders in particular have not profited from a substantial decline in poverty rates in Norway since 1998.
While the percentage of individuals without a mental disorder living below the poverty threshold halved between 1998 and 2008, the share of people with a severe mental disorder living with a household income below 60% of the median remained at the same elevated level.
Norwegians with mental illness have not profited from economic growth People with mental health problems have not profited from economic growth and an expanding labour market in Norway. Both the employment and the unemployment gap have widened between the mid-1990s and mid-to-late 2000s despite a positive economic climate in these years (Figure 1.2, Panel A). The employment rate for individuals with mental disorders has fallen by three percentage points over this period, and the unemployment rate increased by three percentage points (Panel B). Moreover, there is some evidence that skilled workers who immigrated to Norway in large numbers in 2006-09 have displaced Norwegian low-wage earners – including many workers with mental health problems often working in unskilled positions (Jean and Jimenez, 2007; Bratsberg and Raaum, 2012; Bratsberg et al., 2012).
Figure 1.2. In Norway, employment rates of people with a mental disorder declined during the period of strong growth up to the recent crisis
Percentage-point change in employment and unemployment rates for people with and without a mental disorder between the mid-1990s and the mid- to late-2000s
Source: OECD calculations based on national health surveys (NHS) or interview (HIS) surveys.
Australia: NHS 2001 and 2007/08; Austria: HIS 2006/07; Belgium: HIS 1997 and 2008; Denmark:
NHIS 1994 and 2005; Netherlands: POLS Health Survey 20001/03 and 2007/09; Norway: Level of Living and Health Survey 1998 and 2008; Sweden: Survey on Living Conditions 1994/95 and 2009/10;
Switzerland: Health Survey 2002 and 2007; United Kingdom: Adult Psychiatric Morbidity Survey 2007; United States: NHIS 1997 and 2008.
Mental illness is highly prevalent in unemployed and inactive persons Although unemployment is a relatively rare phenomenon in Norway compared with other countries, the share of unemployed persons suffering from a mental disorder is striking. More than every second unemployed Norwegian has a severe or moderate mental disorder; by far the highest number in a sample of OECD countries and much higher than in other
Panel B. Unemployment rates Panel A. Employment rates
-8 -6 -4 -2 0 2 4 6 8
Australia Belgium Denmark Netherlands Norway Sweden Switzerland United States
-8 -6 -4 -2 0 2 4 6 8
Australia Belgium Denmark Netherlands Norway Sweden Switzerland United States
With a mental disorder No mental disorder
highest share of mental disorders among the inactive population (over one-third).
This finding raises some questions. It is unclear in which direction the causality goes, i.e. whether labour market exclusion causes or worsens mental health problems or whether pre-existing mental disorders cause unemployment and inactivity. Evidence from research suggests that both directions work in parallel. The two explanations have somewhat different policy implications. If the high disorder prevalence was caused by exclusion, to increase inclusion should receive even higher priority in Norway. In this case, strategies should target on incentives for people with mental health problems to leave benefits as early as possible. If the inverse were true (mental health problems cause exclusion of the labour market), the question arises why the numbers of people with mental health problems leaving the labour market have increased. In this case, policy would have to develop interventions to mitigate the negative effects of mental disorders on work ability, and increase incentives for employers to retain workers with mental health problems.
Figure 1.3. Mental disorders are particularly frequent among the unemployed Prevalence of severe or moderate mental disorder (in percentage), by labour force status,
latest year available
Source: OECD calculations based on national health surveys (NHS) or interview (HIS) surveys.
Australia: NHS 2007/08; Austria: HIS 2006/07; Belgium: HIS 2008; Denmark: NHIS 2005;
Netherlands: POLS Health Survey 2007/09; Norway: Level of Living and Health Survey 2008;
Sweden: Survey on Living Conditions 2009/10; Switzerland: Health Survey 2007; United Kingdom:
Adult Psychiatric Morbidity Survey 2007; United States: NHIS 2008.
0 10 20 30 40 50 60
Australia Austria Belgium Denmark Netherlands Norway Sweden Switzerland United Kingdom
United States
Employed Unemployed Inactive
Most likely the effects go in both directions, with a selective group of people with a more severe mental disorder drifting into unemployment and disability. The very high rate of mental health problems among the unemployed in Norway suggests that the unemployed are a highly vulnerable group. But the majority of the large group of people, who are inactive for health reasons, most of them with only a moderate mental disability (severe disability is a relatively rare phenomenon), seem to develop a mental health condition or see a worsening of their condition due to their withdrawal from the labour market.
Most unemployed with low education have mental disorders
Not only are income and labour force status, in comparison with other countries, especially unequally distributed in Norway when it comes to mental health, but mental health depends also largely on educational achievement (Figure 1.4). Lower educational attainment goes hand-in-hand with a poorer mental health status, with almost two-thirds of unemployed people with low educational attainment suffering from a mental disorder.
Figure 1.4. The risk of poor mental health varies by education
Prevalence of mental disorders among unemployed (in %), by level of education, latest year
Source: OECD calculations based on national health surveys (NHS) or interview (HIS) surveys.
Australia: NHS 2007/08; Austria: HIS 2006/07; Belgium: HIS 2008; Denmark: NHIS 2005;
Netherlands: POLS Health Survey 2007/09; Norway: Level of Living and Health Survey 2008;
Sweden: Survey on Living Conditions 2009/10; Switzerland: Health Survey 2007; United Kingdom:
Health Survey of England, 2006; United States: NHIS 2008.
10 20 30 40 50 60 70
Australia Austria Belgium Denmark Norway Netherlands Sweden United
Kingdom
United States Below secondary (ISCED0-2) Upper secondary (ISCED3-4) Tertiary (ISCED5-6)
Conclusion on key outcomes in Norway
Norway is in many respects a country of the extremes. No other OECD country combines to such a high degree a high living standard (GDP per capita), and high investments in education and health with a pervasive exclusion of people with health problems from the labour market (Figure 1.5). On the one hand, Norway has the second highest employment rate (75.3% in 2011), the lowest unemployment rate in the OECD area (3.3% in 2011) with a low share of persons being long-term unemployed (around 11.6% in 2011), and a healthy economic situation with a high and growing GDP per head. Furthermore, the income distribution is relatively equal and poverty rates are low.
Figure 1.5. Norway ranks first in several key policy parameters Ranking (1 to 10) of selected countries in a range of policy parameters, latest year availablea
a. Social expenditures, 2007; education expenditures, 2008; dropout and disability recipiency rate, 2009, health expenditures and sickness absence, 2010 and 2011 otherwise.
Source: OECD Education Database, OECD Labour Force Statistics, OECD Social Expenditure Database, OECD Health Expenditure and Financing Dataset and OECD Disability Database.
On the other hand, a large group of people is excluded from the labour market, or threatened by exclusion. Norway has a very high disability benefit caseload, with high inflows and a very low rate of outflows, resulting in high social expenditures. Sickness absence incidence is the highest among OECD countries. Public and mandatory private expenditures on disability
0 1 2 3 4 5 6 7 8 9 10 11
Drop out rate Employment rate
Unemployment rate
Sickness absence rate
Disability recipiency rate
Social expenditures on
Invalidity
Education expenditures
Health expenditures
Norway Netherlands Denmark Australia United Kingdom
Belgium Austria United States Switzerland Sweden
and sickness benefits amount to around 5% of GDP, by far the highest level in the OECD. In addition, many people receive social assistance. In total, almost one-fifth of the population receive income supports due to health problems or disability; nearly everybody who is not working (Duell et al., 2009). Finally, Norway ranks third in the OECD in terms of the costs of the health care system as well as the education system (in both cases after Switzerland and the United States).
The unique combination of healthy general conditions and large benefit dependency rates has remained quite stable over the past decades, despite different waves of reforms and the provision of an elaborate system of vocational measures. Some barriers reflect the specific consequences of the very generous benefit system. This system prevents poverty of ill persons, but it is also a trap, supporting exclusion and the worsening of peoples’
health conditions and quality of life. The Norwegian welfare model provides universal financial protection for both the unemployed and those with a disability, but at the expense of employment for people with (mental) health problems.
There is also another striking combination in Norway of a generous compensation policy for people out of work and a strong vocational integration focus (OECD, 2010a). Norway has one of the most generous benefit systems in the OECD area, with universal population coverage and high financial replacement levels over a long duration or, in the case of sickness and disability, even permanently. However, Norway has also the strongest integration approach, with a range of vocational rehabilitation supports which can be applied at any time and over several years. This finding suggests that the reasons for the exceedingly high labour force exclusion due to health problems in Norway are not simply caused by a lack of support structures or a lack in integration policies in any of the systems involved. Possibly, the problems are more related to the ways, in which all these integration policies and measures have been regulated, implemented, monitored and evaluated.
Organisational characteristics of the systems involved
The relationship between mental health problems and work functioning is complex and, therefore, concerns a variety of different political areas. In addition, every system is organised across different policy layers, with organisations and specific responsibilities on state, county and municipal level. This section briefly describes the characteristics of the involved political and administrative systems relevant in the context of this report:
social protection, education, mental health care and the labour market.
Centralised policies and autonomous municipalities
The state is responsible for policy initiatives, performance control and co-ordination in the area of labour market, social insurance, welfare, and health care policies. National directorates are responsible for policy implementation and professional advice to the municipal authorities. The responsibility for the provision of primary education, primary health care, long-term care and social services lies with the 430 municipalities. In between the state and municipal level, 19 counties are responsible for secondary education, and four regional health authorities for specialised health services.
Although most services are nationally financed and organised, most health, education and social services are provided by the municipalities. The autonomy of the municipalities has a long tradition in Norwegian politics, and it has been reinforced by recent reforms. However, many municipalities are small, with around 50% having less than 5 000 inhabitants, resulting in difficulties to provide the whole range of services in small communities.
Moreover, the autonomy of the municipalities may run counter to the targets of the ministries, e.g.resulting in the protection of traditional and locally rooted but relatively ineffective rehabilitative services such as sheltered workshops, instead of implementing more workplace-oriented supported employment services.
The Ministry of Labour promotes an active labour market policy
The Ministry of Labour is responsible for an active labour market policy to fight exclusion from employment. Norway has traditionally been formulating an active and rehabilitation-oriented approach, by providing a large range of vocational rehabilitation measures in order to get unemployed persons back to work. With respect to the labour market, there is a tradition of tripartite agreements concluded by the social partners and the government.Preventive focus of the Norwegian Labour Inspection Authority The Labour Inspectorate (attached to the ministry) with more than 500 employees oversees that enterprises follow the requirements of the Working Environment Act, including procedures to enable employees on sick leave to return to work. The Inspectorate is responsible for 250 000 enterprises and carries out around 20 000 inspections every year. Recent activities include campaigns related to requirements regarding the sick-leave procedures as well as activities with sectors where workplace conflicts and mental strain are highly prevalent. The possible sanctions for employers in the case of non- fulfilment of the requirements of the Working Environment Act are quite strict in theory, while there are no sanctions for employees.
Health promotion by the Occupational Health Services
Enterprises in branches with a higher risk of work-related injuries, illnesses and strain are obliged to have an Occupational Health Service, regardless of the number of persons they employ. There are around 500 occupational health service units in Norway, covering 20 000 enterprises and almost half of the total workforce. A typical unit consists of a physician, a nurse, an ergonomist and a safety engineer, with limited psychological expertise. The costs of having an occupational health service are covered by the employer. The main focus of occupational health services is prevention and, according to the regulations, services should not be involved in resolving health problems that are not related to the work environment, which is the responsibility of the GP (Lie, 2009). Although such a clear distinction is often not possible in practice, this regulation excludes most mental disorders from support.
Concentrated services by the Labour and Welfare Administration
The Labour and Welfare Administration (NAV) has since 2006 full responsibility for the implementation of labour market policies, the provision of employment and vocational rehabilitation services and early intervention in prolonged sickness absences. NAV is the result of a far- reaching merger of the different employment-related support systems in Norway, namely the Public Employment Service, the National Insurance Service and the Social Assistance Service, in order to ensure more co- ordinated and effective benefits, services and administration. To achieve this, on a municipal level employment and welfare services were concentrated in shared offices. NAV employs around 16 000 professionals in 460 local offices, with a budget of more than NOK 300 billion (corresponding to 30% of the Norwegian state budget.Obligation for close co-ordination between local and state services The third element of NAV, social assistance, is still under the authority of the municipalities, which are obliged to work in close partnership with NAV. However, there are still two chains of command, limiting the impact of national policies in practice. Funding of the benefits and services of NAV and social assistance is also still different; the former being financed by the state and the latter by the municipalities. The 2010 law on social services ensures that local services are co-ordinated with employment services provided by the state agency. The NAV reform has great potential, but so far has paid no attention to mental health care and challenges.
Mental health care is organised on three layers
The organisation of the mental health care system in Norway is based on three layers: primary mental health care is provided by the municipalities, specialised mental health care is under the responsibility of the counties, and the highly specialised hospitals are supervised by the state. An important national organisation is the Directorate of Health, a professional body with three roles as: a health care advisory body to different target groups (e.g. by monitoring trends in health care services); an authority implementing policies (e.g. action plans, campaigns or giving grants); and an administrator of regulations within the field of health care. Together with the Directorate for Labour and Welfare, the Health Directorate has a main responsibility for the implementation and evaluation of the measures of the national strategy on mental health and work.
District psychiatric centres as drivers for decentralisation
In Norway, the process of deinstitutionalisation of mental health care started late compared with other countries. The expansion of community mental health care, organised on the district level (therefore, district psychiatric centres) and staffed with specialists (psychiatrists, psychologists and psychiatric nurses), has been the core of the mental health care reform starting in 1999. The district centres provide specialised services in local environments, and co-operate with hospitals and primary care providers in the municipalities. However, with a responsibility for a population of around 50 000, the catchment area of these centres is rather small (due to the low population density in most Norwegian areas) – limiting the potential for specialised services.
The centres provide ambulatory services, day care, short-term inpatient care, long-term treatment and rehabilitation, consultation, support for primary care professionals and crisis intervention. It is important that the district psychiatric centres are perceived as competent partners by GPs, but this has not always been the case. When asked whether they have a good impression of psychiatric services, around 45% of GPs disagreed (Bjertnaes et al., 2008).
Private psychiatrists and psychologists for adult and child psychiatry Private psychiatrists and psychologists, for adults as well as for children, also provide specialised services. Norway has around 0.2 psychiatrists per 1 000 inhabitants, the second highest number after Switzerland.
Nevertheless, there is a substantial waiting period for persons who do not have a serious mental disorder. Only for people who pay treatment fully out- of-pocket are there no waiting lists. Otherwise, the waiting period is usually
between a few weeks and several months. Since the implementation of the Escalation Plan, the number of psychologists in the municipalities has increased strongly, and today around 3% of the adult population and 4.5% of children and adolescents are in specialised treatment. Thus, the capacity of specialised mental health care has improved over the past 10 years but waiting times are still too long.
Upper secondary education is a separate layer
Compulsory education starts at the age of six and comprises seven years of primary and three years of lower secondary education. The responsibility for the provision of the first ten grades lies with the municipalities, although there is a state curriculum. Afterwards, normally at the age of 16, Norwegian youth have the right to move to upper secondary education, which lasts for three years. This can be general education or vocational training. Upper secondary education is the responsibility of the 19 counties.
Almost all children begin upper secondary education (97% in 2009) but, at around 30%, the rate of adolescents who do not complete upper secondary within five years after entry is relatively high (OECD, 2010b). Only 40%
complete vocational courses in the stipulated time.
Lack of co-operation between school services and mental health care Teachers and students can use a range of municipal or county-based services in the case of mental health problems. Over 150 educational and psychological counselling services (PPS) with 2 000 professionals of which roughly 200 psychologists provide a network across the country. The PPS will refer the student to a specialist health service (via the GP) and give guidance to the school on how to handle students with socio-emotional problems. In the case of behavioural or drug problems, teachers can contact child welfare which is part of the local social service. Students with problems may also contact the school advisor who will guide or refer them to specialists. Finally, there are school health services which are part of the municipal health services and not necessarily located at the school.
Problems arise because none of these services assumes responsibility for the student and because of the lack of co-operation between mental health services and the PPS.
References
Bjertnaes, O., A. Garrat, and T. Ruud (2008), “Family Physicians Experiences with Community Mental Health Centers: A Multilevel Analysis”, Psychiatric Services, Vol. 59, pp. 864-870.
Duell, N., S. Singh and P. Tergeist (2009), “Activation Policies in Norway”, OECD Social, Employment and Migration Working Papers, http://dx.doi.org/10.1787/226388712174.
Lie, A. (2009), “A New Development for Occupational Health Services in Norway”, Scandinavian Journal of Work, Environment and Health, Suppl., pp. 48-52.
OECD (2008), A Learning for Jobs Review of Norway, OECD Reviews of Vocational Education and Training, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264113947-en.
OECD (2010a), Sickness, Disability and Work: Breaking the Barriers. A Synthesis of Findings Across OECD Countries, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264088856-en.
OECD (2010b), Off to a Good Start? Jobs for Youth, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264096127-en.
OECD (2012), Sick on the Job: Myths and Realities About Mental Health and Work, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264124523-en.
Chapter 2
Reconsidering Norwegian sickness absence policies
This chapter provides an in-depth discussion of the development of sick leave against the background of the high level of long-term sickness absence which is the main route to disability benefit in Norway. The chapter discusses the increasing share of long-term sick leave due to milder mental disorders; the role of physicians certifying sick leave; and existing and possible new funding mechanisms for the costs of sickness absences. Finally, eligibility criteria for sick leave due to mental health problems and the use of partial sickness absence are questioned.
The trap of high and prolonged sickness absence
Sickness absence is a major public health problem
The very high sickness absence incidence rate in Norway is a major public health problem (Figure 2.1). Norway has by far the highest rate of work absences of full-time employees in the whole OECD area, with almost 7% of the workforce being on sick leave at any moment. This is almost twice the rate of other Nordic countries, which also have high absence rates relative to other countries.
Figure 2.1. Norway has the highest sickness absence rate by far Incidence of sickness absence of full-time employees in selected OECD countries, 2010a,b
a. 2004 for Australia, 2007 for Iceland, 2008 for the United States and 2009 for Ireland. The incidence of work absence due to sickness is defined as the share of full-time employees absent from work due to sickness and temporary disability (either one or all days of the work week).
Data are annual averages of quarterly estimates. Estimates for Australia and Canada are for full- week absences only.
b. OECD is the unweighted average of the countries shown in the chart.
Source: OECD Absence Database, based on the European Union labour force survey and national labour force surveys for Australia, Canada and the United States.
The annual number of persons on sick leave was nearly 530 000 in 2009 (340 000 in 1994), reporting around 650 000 sickness spells (400 000 in 1994), which is an increase of 59% in sick persons and 63% in sickness spells since 1994 – much more than the rise of the employed population in this period. There are important systemic differences between Norway and other countries with respect to the regulations on sick leave, other benefits
0 1 2 3 4 5 6 7
OECD
and dismissals, which contribute to but cannot fully explain the very high absence incidence (see Box 2.1 for the main characteristics of the sickness benefit scheme).
Box 2.1. Characteristics of the Norwegian sickness benefit scheme
All injured persons are entitled to daily cash benefits in the case of work incapacity due to sickness. The benefit is paid from the first day of absence for a period of 260 working days (i.e. 52 weeks) at a level of 100% of the last wage. In the first 16 days, the employer is responsible for the payment, thereafter the National Insurance Scheme.
Based on both the Working Environment Act and the National Insurance Act, different meetings must be held between the employer, the employee, the NAV officer and possibly, the treating physician, in order to shorten the absence duration. If such meetings are not held, there may be sanctions. Generally, GPs are supposed to motivate their patients to continue working if possible and to consider whether partial sick leave would be an option.
The employer must initiate a follow-up plan in co-operation with the employee before the end of the 4th week of sick leave, setting out what steps are needed for an employee to be able to continue to work, at least on a partial basis. The plan includes: i) an evaluation of the employees’ tasks and work ability; ii)relevant adjustments from the employer; iii) the need for external assistance; and iv) a follow-up plan. This plan must be sent to the treating physician. The only exceptions to this rule are if it is clear that the employee will return to work without any adjustments, or that the employee will be unable to return to work.
After seven weeks of sick leave, the employer must hold a meeting with the employee to update the follow-up plan. If necessary, the certifying doctor must be present. Within nine weeks the employer must send the updated plan to NAV. Within eight weeks the treating doctor has to report extended sick leave, and must document the medical reasons why work is not possible. The NAV office must organise a second meeting within the first 26 weeks of sick leave. This meeting is mandatory for all the actors.
Increasing share of sick-listed employees due to mental health problems
During the same period, the health conditions composition of absentees has changed (Figure 2.2). The share of persons who are sick because of mental illness rose by eight percentage points, from 10% to 18% between 1994 and 2010, while the share of musculoskeletal disorders fell from 50%
to 41% in the same period, with all other medical conditions remaining stable. The number of sick persons with mental disorders rose by a factor of 2.6 from 34 000 to 88 000 in 2010, and the number of persons with musculoskeletal disorders increased by a factor of 1.2 from 170 000 to 203 000.